The Health CIO Network is our new network of networks for IT directors and others with leadership roles in healthcare IT and will be running its own events later in the year. Check out its pages on ehi.co.uk for more information, or email me (jon at e-health-media.com) for more details.

US healthcare IT leaders are coming under growing financial pressures, with their top business priority being to sustain financial viability in the face of massive pressures including falling reimbursements and mergers.

The second related top business priority is to improve the operational efficiency of care, followed by clinical improvement.

Jennifer Horowitz, the vice president of HIMSS Analytics told a media briefing in Orlando this morning: “Changing payment models was a top concern, as were policy mandates and financial considerations.”

She said the findings of the annual HIMSS Leadership Survey were “No surprise with changing reimbursement models and the introduction of accountable care”.

The poll of US healthcare IT leaders showed that worries about lack of financial resources is now the number one barrier to delivering IT strategies, displacing worries about lack of staffing resources, which was cited as the main concern in 2013.

The three top priorty areas for staffing were staff with skills in clinical application support, network architecture support and clinical informatics. “These have been the same top areas for the last few years, said Horowitz.

The findings also indicate that the majority of US hospitals plan to continue increasing IT spend. Some 65% of those surveyed said they expect their operating budget to increase in the next year, a figure slightly down from 76% last year.

Asked to identify their priorities for the next two years achieving meaningful use was named as the highest priority, with a high degree of optimism about meeting the requirements on stage one and two.

Some 90% sad they have already reported meeting stage one and 71% said they believe they will meet stage two by the end of 2014.

Topping the list of financial priorities was converting to ICD10, with a national switch planned by 2014. Some 69% say that is their primary financial IT focus, and 92% say they are ready to meet this requirement.

Healthcare CIOs need to wrestle back control of the technology agenda from government if they are to drive improvements in productivity.

CIOs in the US healthcare industry need to seize back the initiative on technology and make the case for investment in information technology as the driver of transformative change in healthcare.

To do so they must grasp the nettle on proving return on capital investment and IT as a strategic driver of productivity, argued Saum Sutaria, MD, director healthcare systems and services, McKinsey.

Dr Sutaria told the CHIME HIMSS CIO Summit in Orlando that healthcare “has failed to increase productivity and that IT is still viewed as a cost centre by most Chief Executives and Chief Financial Officers”.

“You have got to take control of technology agenda from what has been government regulated. Otherwise you will find it very different to change peers views that technology is a cost.”

Too much attention had been paid to chasing meaningful use dollars rather than thinking about how technology is used to deliver transformative change.

He told the assembled US CIOs: “This coming era may be when this group of individuals has to take more action based alternatives.”

“Should the tech strategy actually drive the business strategy in healthcare for a change?”

With massive healthcare in the US the biggest financial reality facing most providers was cuts in medicare reimbursements. “This has got to be about better more efficient care that is information enabled. Number one priority is to get more efficient.”

But Dr Sutaria sad the current wave of provider mergers would not drive real productivity. “Most of value from mergers and acquisitions is coming from the old bag of tricks: raising prices and cutting overheads.

However, CIOs are not yet stepping up to take on the leadership challenge of productivity and making the running in the board room. But nor is anyone else.

“A lot of people on CIO shop are being shrinking violets on where is the ROI coming from this huge investment. How do we get the return? We don’t want to admit that today. “

Taking a tough realistic line on what the return on investment was for capital intensive investments is against cost of capital would result in different types of investment decisions.

“You’ll find that a lot of traditional infrastructure heavy investments just don’t meet the bar,” said Dr Sutaria.

He added: “The first step is to wrestle the technology agenda from government. “We’ve seen orgs chase meaningful use dollars and then it just stops. But meaningful use dollars don’t come close to delivering return on the investment needed.”

The McKinsey director called on the audience of CIOs to rise to the challenge. “Many of executives in this room have the ideas that could transform healthcare delivery but not be willing to put that agenda on the table, and traditional management not being willing to put on the table either.”

To take on this daunting challenge he urged CIOs to form new alliances on productivity. “This group could do more to identify coalitions in their organisations outside their current walls.”

One key axis for CIOs to lead on is how to engage with consumers, “Need to step outside of normal world, engaging with consumers, find out what they want and use that to drive changes in operations

He added: “Some 80% of what physicians do could be done better by computer. And it’s the 80% of what they do that needs to be changed to get better decisions and patient outcomes.”

He concluded; “We have the most educated service workforce in any industry today and greater variability.”

Meaningful use, the $30 billion US investment programme in Electronic Health Records, has reached a crossroads. Where it goes next could have important implication for the whole healthcare IT industry.

With $21 billion spent by the Office of the National co-ordinator so far meaningful use has reached maturity and is coming under intense national scrutiny.

Begun back in 2011 as part of the HITECH health IT investment initiative, itself part of the US economic stimulus act, meaningful use has accelerated adoption of EMRs in hospitals and physician offices, with 80% of hospitals having received incentive funds and 50% of physician offices.

Advocates say that in just three years meaningful use has enabled the US healthcare system to reach a critical mass and achieve a tipping point.

Meaningful use comes in three stages, each more demanding than the last. Stage one set fairly basic requirements that most healthcare providers were able to meet by going out and buying an electronic health record system and beginning to use it.

Stage two, due to come into force in 2014, however goes much further than use of electronic records, focusing on sharing them — with different parts of the hospital, with other hospitals, and with patients

Stage two also creates more clinical quality measures to track; suppliers must demonstrate interoperability (both creating and pushing records as well as consuming and populating them) with at least one other EHR, and systems must let patients view, download and transmit their own electronic records.

Stage three of meaningful use, due in 2016, raises the bar even further with a focus on improving quality, safety, and efficiency, leading to improved health outcomes.

Healthcare providers and suppliers are struggling to meet the demanding stage two requirements in full. A study by the Centers for Disease Control and Prevention found that only 13 percent of physicians have an EHR that meets stage two criteria.

Should policy makers consolidate on progress achieved over the past three years, and ensure benefit is achieved from systems now in use; or should they double up efforts on interoperability, clinical quality, driving workflow improvements, and patient enablement?

A significant number of critics say the surging adoption numbers mask some real problems, including many users unhappy with the usability of EHR systems that have bought and installed to achieve meaningful use incentives.

Some healthcare providers have found that the electronic record systems they implemented to met stage one don’t have the functionality or are not user friendly enough to meet the requirements of later stages.

John Moore, managing director of Chilmark Research, believes the short-term stimulus monies have acted like steroids and have created a boated “false market” that led many providers to implement rigid, inflexible EHR systems, with poor usability and customer service to boot.

In an interview with CIO magazine he added that incentives mean EHR vendors have not been forced to innovate sufficiently and ensure that they deliver a great user experience.

A 2013 report by Black Book Rankings, meanwhile, suggested that as many as 17% of medical practices were so frustrated with their new electronic record systems they were planning to rip and replace them.

Others worry that meaningful use has widened the digital divide in US healthcare. Meaningful use only covers healthcare providers receiving Medicare funding. Behavioral health, most pediatricians and long-term care providers are not covered.

Other concerns focus on rural and critical care providers falling behind on bringing the investment needed for the next stage of meaningful use.

Perhaps the biggest issue is that meaningful use is just one of a wave of initiatives hitting the industry simultaneously. New government requirements, a decline in reimbursement and massive change in the delivery system, including a huge wave of mergers are all occurring at once.

Added to this entire industry also due to implement ICD10 in October, a change that carries huge costs for A recent report suggested that physician practices in particular would struggle to meet the cost. ICD10 implementation has already been delayed once.

Russ Branzell, president of the College of Health Information Management Executives (CHIME), says some CIOs are struggling with the degree of change. “The amount of change hitting us at once means there is a perfect storm for some.”

Braznell says that CHIME still strongly supports meaningful use, but Healthcare CIOs are facing multiple challenges piling up on them at once.

A year ago, health secretary Jeremy Hunt announced that he wanted to see a ‘paperless’ NHS by 2018.

Twelve months on, the idea remains an important clarion call to action, without a huge amount of clarity on what paperless means, why it should be achieved, or how it will be taken forward.

Literally paperless a pipe dream

Almost nobody working in NHS IT believes in the objective in a literal sense. There is not a chance the NHS will have ceased to use paper within four years. Stationers and printers across the land can sleep a little easier.

Instead, at the top level, a ‘paperless NHS’ is a national policy initiative that succinctly conveys the urgent need to digitise England’s hugely complex, fragmented national health and care services, to help to achieve a host of pressing productivity, efficiency and clinical safety challenges.

The big question is how this can this be achieved when the NHS is facing a historic squeeze on budgets. Where are the priorities?

Or, to put it another way, what are the main business objectives of a drive to a paperless NHS? Many different and sometimes contradictory answers have been offered over the past 12-months.

Paper mash-up

Is ‘paperless’ primarily about clinical systems; replacing paper records with a drive to integrated digital health and social care records?

This was the clear direction provided by NHS England, when it published its ‘Safer Hospitals, Safer Wards: Achieving an Integrated Digital Care Record’ guidance last July. But the term has been used much more loosely, and for a much wider range of initiatives, even within the acute sector.

Or, is paperless really about catalysing a fundamental shift to online digital services, as seen in many other industries?

Is it meant to dramatically change the way in which many NHS services are delivered, create genuinely patient centred services, challenge many current professional roles, and drive productivity by eliminating a lot of jobs?

That’s the way that NHS England’s director of patients and information, Tim Kelsey, talks (except for the bit about eliminating jobs); and he clearly has Hunt’s ear – meeting him once a fortnight.

However, it has yet to be translated into working projects at a national level, never mind at a local one.

There is a growing air of frustration coming out of NHS England that numerous, brilliantly conceived websites and open data initiatives aren’t being realised and don’t seem to be solving knotty problems like A&E.

Tensions are also mounting between NHS England and the Health and Social Care Information Centre.

Which brings us to: is paperless really about marshaling, linking together and analysing the data resources of the NHS for the benefit of patients, but also public health statisticians, researchers and the life sciences industry – and, in so doing, save UK Plc?

Certainly, this seems to be the HSCIC agenda, and one that is put forward when presenting to ministers – including the prime minister, who has made several references to it at international conferences.Papering over the cracks

But as a basis for formulating coherent strategy, it has so far proved of limited explanatory value. It has been extremely difficult to translate it into a set of clearly articulated national priorities that local organisations can then translate into local business plans and strategies.

This has not been helped by the different dates that have been put on the milestones on the digital journey, or by the handling of the Safer Hospitals, Safer Wards: Technology Fund that is supposed to fund them.

Although Hunt set out his vision last January, the first mention of paperless was made three months earlier at a London conference by Kelsey, who said he wanted the NHS to be paperless by 2015.

There followed some quick back-tracking, suggesting the focus of his remarks was electronic referrals and discharge letters; but while the new e-referral service will be live by then, the deadline for paperless referrals is now 2017 or 2018.

As a foundation, he suggested the NHS should have records “that can talk to each other” by 2015; but this date has not found its way into subsequent, national guidance.

Meanwhile, a report by PriceWaterHouseCoopers to support Hunt’s speech suggested that the NHS could save £4 billion if the NHS invested in technologies ranging from records to document scanning to telehealth.

This was a major online consultation exercise, working with partners including NHS England, that found very strong support for a focus on electronic records and clinical systems that offered clear benefits to patients.

The results helped inform the development of the Clinical Digital Maturity Index, a benchmarking tool developed by EHI Intelligence to measure trust’s progress on installing clinical IT systems, now licensed on behalf of the NHS by NHS England.

It also appeared to inform and was in tune with the initial priorities for the tech fund. Hunt launched this in May with £260m of unspent capital funds, a figure that would later be increased to £500m, or, as he put it, “£1 billion for NHS IT” over three years, counting in matched funding from trusts.

At this point, it looked as though the Department of Health had decided that e-prescribing – one of the most critical elements of a hospital EPR system, offering measurable patient safety benefits – would be the focus of extra investment.

The move looked extremely shrewd. E-prescribing is a catalyst to driving clinical benefits, but almost impossible to achieve in isolation from a good infrastructure and other clinical information systems. Get one, and you’ll actually get the others.

And as NHS England sought to juggle competing priorities, and the practicalities of getting the first round of hot money spent by the end of the financial year came into view, even this focus was also lost.

The tech fund instead became available for a much wider range of projects including, but not limited to, portals, electronic document management, and mobile initiatives.

At least, that’s to judge from the initial announcements about winning bids that came out in December, many of which appear to be for ‘shovel ready’ projects that trusts had in hand, and might have taken forward in any event.

Time to take a fresh view on paperless priorities

With round two of the tech fund now about to kick off, it makes sense to take stock on ‘paperless’, now both a year old and due to be completed in just four years.

No successful commercial organisation would set ‘paperless’ alone as an objective. It would, instead, have particular business goals that it would aim to harness digital tools and data to deliver. The NHS urgently needs to find a way of adopting the same thinking.

What investments in clinical and business IT will result in ‘meaningful use’ that can deliver the greatest measurable benefits to patients and NHS providers? How can these be turned into a sensible, funded strategy that will make sure those benefits are delivered and can be measured?

And how can the experience of the different parts of the NHS be better shared and learned from, so successes can be scaled up? NHS England is promising that a technology strategy, delayed from December, will now be out in March. A lot may hang on it.